Patient presents with symptoms suggestive of a psychiatric problem.  Presenting concerns include (list chief complaint e.g., depressed mood, anxiety, insomnia, difficulty concentrating, irritability, fatigue, changes in appetite, feelings of hopelessness, worthlessness, or guilt, thoughts of self-harm or suicide, hallucinations, delusions, disorganized thinking, or unusual behavior).  Onset of symptoms reported as (duration and timing of symptom onset).  Precipitating factors may include (list potential triggers e.g., stressful life events, relationship problems, financial difficulties, medical conditions, or substance use).  Patient reports (describe the patient's subjective experience of the symptoms, including their severity, frequency, and impact on daily functioning).  Mental status examination reveals (describe the patient's appearance, affect, mood, speech, thought process, thought content, perception, cognition, insight, and judgment).  Differential diagnoses considered include (list potential diagnoses e.g., major depressive disorder, generalized anxiety disorder, bipolar disorder, schizophrenia, post-traumatic stress disorder, substance use disorder).  Based on the patient's presentation, history, and clinical findings, the preliminary diagnosis is (state the most likely diagnosis).  Further evaluation is recommended to confirm the diagnosis and rule out other potential conditions.  This may include (list recommended assessments e.g., psychological testing, laboratory tests, imaging studies, or consultation with a specialist).  Treatment plan includes (describe the initial treatment plan e.g., psychotherapy, medication management, referral to community resources, or hospitalization).  Patient education provided regarding (list topics covered e.g., the nature of the diagnosis, treatment options, potential side effects of medications, coping strategies, and relapse prevention).  Follow-up appointment scheduled for (date and time) to monitor treatment progress and adjust the treatment plan as needed.  Patient’s prognosis is (describe the expected outcome based on the diagnosis and treatment plan).  Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) codes relevant to this encounter include (list appropriate codes e.g., for psychiatric diagnostic evaluation, psychotherapy, and medication management).